Managing primary care patients' risky drinking

Centers for Disease Control Director Thomas Frieden, MD, wants more physicians to screen patients for risky alcohol consumption. From a public health viewpoint, this makes great sense. Even at levels of consumption well below what are common among people whom we think of as “alcoholic,” heavy drinking is a risk factor for injuries, accidents and assaults. Ethanol can also interact dangerously with medications a doctor may prescribe (e.g., ibuprofen and other pain relievers, sleeping pills).

But historically, three barriers have stood in the way of physicians screening more patients for risky drinking:

Knowledge: There’s an old joke that using metal detectors to stop people from carrying guns (e.g., into schools) seems like a great idea up until the moment the detector goes off. If you screen for something, you’ll find it at least some of the time and be expected to respond. Some doctors don’t screen for risky drinking because they wouldn’t know what to do if they found it. Fortunately, over the past 20 years a brief counseling intervention has been developed and proven effective in multiple clinical trials. It’s an easily learnable technology that physicians find they can use across a range of patient health behaviors. But still, like any other clinical practice, it takes a long time to make these effective interventions a routine part of medical education and front line care

Reimbursement: Primary care doctors typically have a lot of work to do with each patient in a short amount of time. It was therefore hard to persuade them for many years to address risky drinking by patients, particularly as it was not a compensated activity. That has now completely changed with the creation of billable codes for screening and brief intervention for heavy drinking, the provision of a problem drinking screening benefit in Medicare and the Affordable Care Act’s inclusion of these interventions as an essential preventative healthcare benefit.

Psychological discomfort: The late Barry Rosen, MD, an outstanding addiction specialist and teacher, once listened to a psychiatric resident in my addiction medicine course say that asking patients about how much they drank was “too invasive, even rude.” Barry responded, “You think that’s invasive and rude when we are both part of the one profession that tells total strangers to ‘go into that examination room and take off all your clothes?’” Medical training should help doctors overcome their reticence by pointing out that if you can give a stranger a digital-rectal exam, draw their blood, tell them to take powerful medications and ask them about their safe sex practices, you can also ask them how much alcohol they drink.

In the future, as medicine becomes a team sport, doctors may oversee the care of risky drinking patients but not provide it directly themselves. One potential model of primary care is to have the team include a “habit specialist” who would use motivational counseling, behavioral change planning and monitoring to help patients with health behavior problems. This would certainly include heavy drinkers trying to cut consumption, but would include people attempting to lose weight, quit smoking and adhere to their diabetes care regimen. The VA is using psychologists in this role; Geisinger Health is using nurses. Both models seem a promising way to manage heavy alcohol consumption and other problematic health behaviors; it remains now to see whether they reduce the need for the acute care sufficiently for them to be economically viable across the entire health care system.